Fundamentals Exam 2 Flashcards
Name the six types of skin dicoloration
Cyanosis Pallor Jaundice Erythema Ecchymosis Petechiae
bluish discoloration typically assessed in nail beds, lips, mouth, conjunctiva
Cyanosis
decrease in tissue oxygenation
absence of underlying red tones in the skin
in brown skinned clients, skin may appear as a yellowish brown tinge
in black skinned clients, skin may appear ashen gray
usually assessed in areas with the least pigmentation:
- conjunctiva - oral mucous membranes - nail beds - palms of hands or soles of feet
Pallor
yellowish orange discoloration typically assessed in sclera, mucous membranes and skin
Jaundice
reddened areas of the skin
Erythema
areas of bruising on the skin
Ecchymosis
pinpoint sized, red or purple spots caused by small hemorrhages in the skin layers
Petechiae
From the RYB color code of tissue.. what does a red, moist tissue mean?
PROTECT/COVER THE TISSUE
Granulation tissue which is progressing toward healing
Skin needs to be protected to avoid disturbing regenerating tissue
In what ways do you protect the skin to help avoid disturbing the regenerating or healing tissue?
Gentle cleansing Protect skin around wound Fill space in wound Cover with appropriate dressing Change as infrequently as possible
From the RYB color code of tissue.. what does yellow tissue mean?
CLEANSE THE TISSUE
There is slough present (stringy substance attached to wound bed – may be accompanied by purulent drainage)
Must be removed before the wound can heal
- Irrigate wound - Apply wet to damp normal saline dressings
From the RYB color code of tissue.. what does black or brown tissue mean?
DEBRIDE THE TISSUE
There is eschar present (Necrotic tissue)
Must be removed before healing can occur – called “Debridement”.
Name the beginning components of a skin assessment
Examine the upper extremities while the client sitting
Remove stockings/stocks to expose the lower extremities
Compare Bilaterally
Examine lesions individually
Use an assessment tool to predict pressure-ulcer risk
Inspect and Palpate Simultaneously
Have Proper Equipment
What are some more specific things to look for when performing a skin assessment?
Temperature (should be warm to touch)
Texture/feel of the skin
Turgor (the skins elasticity.. skin should snap back when pinched and if not then the turgor is poor)
Edema (swelling from excessive fluid in the tissue)
-palpate area – if fingers leave an indentation, it is called pitting edema
Lesions
What are the 4 types of wound drainage?
Serous- clear and watery
Sanguineous- bright red
Serosanguineous- pale, red, and watery
Purulent- thick, yellow, green, tan, or brown
Localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time
Pressure ulcer
The decrease in blood supply of a pressure ulcer is called..
Ischemia
What is reactive hyperemia?
When pressure on the skin is relieved and turns red from vasodilation because extra blood flow is getting to the area. If redness does not dissappear then there is most likely tissue damage
Describe a stage 1 pressure ulcer
An observable change
Redness
No open skin areas
Describe a stage 2 pressure ulcer
Partial thickness skin loss involving epidermis/dermis
There is now a superficial break in the skin
Abrasion, blister, or a shallow red/pink crater
No slough (which is white and yellow drainage)
Describe a stage 3 pressure ulcer
Full thickness skin loss involving damage or necrosis (death) of subQ tissue
Deep crater
There is no visible bone/tendon/muscle but slough may be present
Describe a stage 4 pressure ulcer
Full thickness skin loss with extensive destruction Tissue necrosis (death of tissue) Damage to muscle, bone, or tendon Slough or eschar (necrotic tissue) may be present
What is an unstageable ulcer?
A suspected deep tissue injury that will look like a bruise but underneath is developing a stage 3 or 4 pressure ulcer
Documented as unstageable, NOT stage 1
What makes an ulcer unstageable?
Full thickness tissue loss where the base is covered by slough (yellow/tan/gray/green/brown) or eschar (tan/brown/black) to the point where the depth nor stage of the wound can be determined until the slough and eschar is removed
Wounds often misclassified as pressure ulcers
Skin Tears Arterial Ulcers Venous Ulcers Diabetic Ulcers Perineal Dermatitis
What are the 3 phases of wound healing?
Inflammatory
Proliferative
Maturation
Assessing pulse
Most commonly assessed peripherally (radial pulse) and centrally (apical pulse)
Normal pulse is 60-100 beats/min
- above 100: tachycardia
- below 60: bradycardia
Assess normal, bounding, or weak pulse
Regular or irregular rhythm
Normal arteries will feel straight, soft, and smooth
Abnormal arteries will feel twisted and hard
2 nurses should take radial and apical pulse at the same time and radial will never be greater than apical
Assessing blood pressure
Measured in mmHg
Systole is peak force
Diastole is minimum force
The difference between the two is called pulse pressure and its normally 40mmHg
Normal is around 120/80
Hypotension is a BP below 100/60 consistently
Hypertension is a BP above 140/90 mmHg consistently
Pre-hypertension is a BP between 120/80 and 139/89
Assessing respirations
Normal adult respiration is 12-20 times/min
Inspiration lasts 1-1.5 seconds
Expiration lasts 2-3 seconds
Looks for depth: shallow or deep breaths?
Look at rhythm: regular or irregular breaths?
Normally silent
Symmetric lung expansion
Lung ascultation
Assessing pulse oximetry
Taken at the same time as regular vital signs
Measures arterial blood oxygen saturation
Sensor usually placed on finger, possibly toe nose or earlobe
Normal is 95-100%
Below 70% is life threatening
Assessing temperature
Normal is 98.6 but anywhere from 97-99
Adults over 70 can range from 95-99
Assessment Sites: Mouth (PO): 3-8 minutes Rectal: 2-4 minutes Axillary (Ax): 10 minutes Tympanic (seconds) Forehead / Temporal Artery (seconds)
Complication with oxygen therapy
O2 ehances combustion and a fire will burn more readily
Prohibit smoking
All electrical equipment must be grounded
Repair frayed cords that can spark and ignite a flame
Prohibit any flammable solution containing alcohol or oil.
Oxygen toxicity
Damage to lungs can occur.
Initial symptoms include: nonproductive cough, substernal chest pain, GI upset, and dyspnea.
With continued exposure to high concentrations of O2, symptoms become more severe.
Structural damage to lungs can occur
Drying of the mucous membranes
When O2 flow rate is higher than 4 L/min, humidification is usually added to the delivery system.
Monitor water level and change humidifier as needed.
The humidification system may be a source of bacteria as well as the delivery equipment.
Change equipment per agency policy
can range from 1-7 days.
Nursing care for a patient using oxygen therapy
Cleanse the cannula or mask by rinsing with clear, warm water every 4-8 hours as needed
Check the skin around the ears, back of neck and face for pressure points and signs of irritation.
Provide mouth care prn
Assess nasal and oral mucous membranes for signs of dryness.
Pad tubing in areas that put pressure on the skin.
Lubricate nostrils, face, and lips to relieve drying effects of oxygen –Do not use Petroleum Jelly – it is combustible!
Position tubing so it does not pull on face or nose.
Ensure that there is no smoking in the area.
Assess and document response to therapy.
Make sure equipment is operating properly
Increases workload of heart
This increases oxygen demand and blood flow
Also causes damage to blood vessels and increases development of atherosclerosis
Diet can play a role in treatment
Hypertension
High blood sugars are linked with increased development of atherosclerosis, increased lipids and triglycerides
Diabetes
Elevates serum lipids
Increases blood coagulation
Increases blood pressure
Stress
Edema characteristics
-collection of fluid in the interstitial
compartment
-be sure to note amount, extent, and type
-edema can be generalized or confined to a
body part
-always compare extremities
-Independent edema has swelling all the time
-Dependent edema swelling goes away after awhile
-Pitting edema: feels soft and leaves
an imprint when finger pressed against skin
-Brawny: feels hard or gelatinous
skin looks shiny, moist, no pitting
Describe the process of defecation
The expulsion of feces from the anus & rectum called a Bowel Movement (BM)
Frequency and amount varies from individual to individual
Peristaltic waves move feces into rectum where client becomes aware of need to defecate
When client is on toilet or bedpan the external sphincter relaxes and feces is ex-pulsed
If defecation re-flux is ignored or external sphincter muscle is contracted consciously, the urge to defecate will disappear for a few hours before occurring again
What are the 10 factors affecting defecation?
- Age: defecation lessens with age
- Diet: bulk foods are necessary to provide volume
- Fluids: soften stool and increase peristalsis
- Activity: stimulates peristalsis, also if you have weak muscles you are less likely to control your bowels
- Psychological factors: anxiety and anger can increase peristaltic activity, depression can slow it resulting in constipation
- Defecation habits: don’t ignore the urge because the longer you wait the harder it will be to expel
- Medications: check to see if side effects affect elimination
- Diagnostic procedures: barium can cause constipation and diarrhea
- Anesthesia and surgery: may cause slow or ceasing movements
- Pain: may suppress the urge to defecate if pain is experienced resulting in constipation
Describe the normal assessment of feces
Color: normally brown
Consistency: normally formed, soft, semi-solid, moist
Shape: clyndrical, shape of rectum
Amount: varies with diet
Odor: affected by ingested foods or medications
Constituents: undigested food, etc.
Abnormal findings on feces color
If its clay or white: absence of bile pigment
Black or tarry: Iron, upper GI bleed or diet high in red meat & dark green veggies
Red: lower GI bleed, some foods (beets)
Pale: diet high in milk & milk products and low in meats, malabsorption of fats
Orange or green: intestinal infection
Abnormal findings on feces odor
Pungent: infection or blood
Abnormal findings on feces consistency
If its hard, dry stool: dehydration or decreased intestinal motility
Diarrhea: increased intestinal motility
Abnormal findings on feces shape
Narrow, pencil shaped, or string like: indicates obstructive condition of rectum
Abnormal findings on feces constituents
Pus – bacterial infection Mucus – inflammatory condition Parasites Blood – GI bleed Fat - malabsorption
What is an Occult Blood test and how does it work?
It detects GI bleeding
- Use a tongue blade to place a small amount of stool on a slide
- Place a few drops of reagent onto smear
- Observe for color changes
- Blue - a guaiac positive
any other color is negative
List the steps in collecting a specimen of feces
- Have pt defecate into clean bedpan or
commode - Try to avoid contact with urine & tissue
- Use tongue blade to transfer specimen to container
- Usually need 1 inch or 15-30 ml of liquid stool
- May need all of stool for a timed test
A mass or collection of hardened feces
Fecal Impaction
Dilated veins in anorectal area
Hemorrhoids
Temporary or permanent artificial opening in the abdominal wall
Stoma
Solution introduced into the rectum and large intestine. Promotes defecation by distending the intestine, irritating intestinal mucosa, or softening the feces (lubricating rectum) to increase peristalsis
Enemas
Which enema is the safest?
Isotonic, because there is no movement of fluid between the colon and interstitial fluid
Normal assessment of urine
I & O: 60 ml/hour (1500 ml/day) is normal for the kidneys
Color: pale straw or amber colored
Clarity: transparent, no sediment
Odor: ammonia in nature, concentration urine (not a lot of water) is very strong smelling
Amount: each void should be every 24 hours/every day
Describe the clinical significance of the urine pH
Acidic pH: starvation, diarrhea, diet high in protein
Alkaline pH: UTI, diet high in fruits & vegetables
Describe the clinical significance of specific urine gravities
Elevated (concentrated urine) means dehydration
Decreased (diluted urine) means over-hydration
List 4 things that should NOT be present in urine
Glucose: could be indicative of Diabetes
Ketone bodies: could be indicative of Diabetes or starvation
Blood: could be indicative of UTI, kidney disease, renal calculi
Protein: could be severe stress or renal disease
Ways to prevent a UTI
Avoid tight fitting pants (irritation to urethra and prevents ventilation of perineal area)
Wear cotton underwear
Women need to wipe and clean from front to back
Shower rather than bathe (bacteria present in bathwater)
Encourage to void at least every 4 hours
Cranberry juice (acidifies pH of urine)
Urinating after sexual intercourse
Improves blood flow to body part
Promotes delivery of nutrients and removal of wastes
Lessons venous congestion in injured tissues
Vasodilation
Effects of local heat
Assist in wound healing
Promote drainage (drawing out infected material out of wounds)
Reduces inflammation and infection
Relieves local pain, stiffness, or aching, particularly of muscles and joints
Reduces blood flow to the area
Promotes blood coagulation at the site of an injury
Reduces oxygen needs of tissues
Vasoconstriction
Effects of local cold
Vasoconstriction
Decreased tissue sensitivity
Local anesthesia/relieves pain
Shivering
Slows or stops bleeding/fluid loss
Slows bacterial activity in clients with an infection
Reduces swelling in injured tissues, including sprains and fractures
Heat produces maximum vasodilation in 20-30 minutes.
After that, reflex vasoconstriction occurs
This is called ______ meaning its not helping
Heat should not be applied for longer than the 30 minutes – allow 30-60 minutes for the tissue to recover before applying heat again to the same area
Rebound effect
Cold produces maximum vasoconstriction in 10-30 minutes.
______ occurs after this.
Apply cold for no longer than the 30 minutes and allow tissue to recover for 30-60 minutes before applying cold again to the same area.
Rebound vasodilation
